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One Day in the Life of a Meaningful User

All the laws have been passed and all the final rulings have been published. In the spirit of the times, you went out and got yourself an EHR. You did your due diligence and sat through many hours of vendor demonstrations. In the end they all started to blend together, so you talked to friends and colleagues and accepted the Hospital’s offer to pay a big chunk of your EHR costs if you picked the one they wanted you to pick.

Your biller quit in disgust, but other than that the implementation was uneventful and the Hospital folks helped a lot. After several hiccups, your Medicare payments are coming in regularly now and your office is adjusting well to the new software. The documentation templates leave a lot to be desired, but you type well and when you find some free time you may take a stab at customizing them a bit. Here and there you run into bugs and a couple of times the EHR was unavailable for a good two to three hours. Not sure exactly why. Maybe it was the Internet that was unavailable.

Anyway, if all goes according to plan, you will be retiring in 10 years and your much younger partner will be bringing in someone who is probably in Medical School right now. Everything seems under control. But today is different…

Today is January 2nd, 2011 and you are driving to work. Today has to be meaningfully different and your first patient is waiting in Exam Room 1.

Mrs. Kline is a pleasant 68 year old woman, who has been seeing you for ten years or so, for her hypertension (which is well managed), hyperlipidemia and a touch of arthritis. You bring up her chart on your EHR and begin your meaningful use (§ 495.6(d)(7)(i) – Record Demographics – Check). There is a little red sign on the screen saying that Mrs. Kline is overdue for a routine mammogram (§ 495.6(d)(11)(i) – Clinical Decision Support – Check). She says that she got a little postcard from your office the other day (§ 495.6(e)(4)(i) – Patient Reminders – Check) and will be making an appointment soon. You look at the BP recorded by the nurse and also notice that Mrs. Kline gained some weight and her BMI is now well over 30 (§ 495.6(d)(8)(i) – Record Vitals and BMI – Check). You chuckle as you notice that the nurse duly noted that Mrs. Kline does not smoke (§ 495.6(d)(9)(i) – Record Smoking Status – Check). As you listen to Mrs. Kline’s account of her knees “acting up” again and how it is now painful to walk Fluffy in the morning, you glance at her problem list (§ 495.6(d)(3)(i) – Maintain Problem List – Check) and medications (§ 495.6(d)(5)(i) – Maintain Med List – Check). She also mentioned some shortness of breath when walking Fluffy and you proceed to do an examination.

As you look over Mrs. Kline’s slightly swollen knees and check her wrists and elbows too, she tells you about her daughter Ellie and how she is now a third year Dermatology resident. Mrs. Kline is hesitantly wondering if her daughter could peek at her medical records once in a while. Sounds reasonable and you tell her to ask Mary at the front desk to set her up with access to the portal (§ 495.6(d)(12)(i) – Electronic Copy of Medical Records – Check). You explain to her that all her records are on the computer now and even today’s visit summary will be there before she gets home (§ 495.6(d)(13)(i) – Provide Visit Summaries – Check) and (§ 495.6(e)(5)(i) – Timely Access to Medical Records – Check). Her daughter in faraway California should be well informed from now on.

The exam was non eventful and the Lipid panel Mrs. Kline had last week looks good (§ 495.6(e)(2)(i) – Incorporate Lab Results – Check). You proceed to write a new prescription for Celebrex (§ 495.6(d)(1)(i) – CPOE for Meds – Check) and note that she is not allergic to anything (§ 495.6(d)(6)(i) – Maintain Allergy List – Check). The obligatory DDI pops up and you dismiss it as duly noted (§ 495.6(d)(2)(i) – Drug-Drug Interaction – Check). You adjust the BP meds and note that everything is on formulary (§ 495.6(e)(1)(i) – Formulary Check – Check). You ask Mrs. Klein which pharmacy she is using and promptly send all her scripts there (§ 495.6(d)(4)(i) – Electronic Prescribing – Check). On your way out you talk to Mrs. Kline about the need to monitor her blood pressure carefully now that she is on new meds and to call you if anything changes before her next appointment. You say good bye and good luck to her daughter. Mrs. Kline stops by the front desk and Mary sets her up with a portal account, makes an appointment for her and hands her the BP home monitoring education materials you ordered (§ 495.6(e)(6)(i) – Patient Education Materials – Check). Your next patient is in Exam Room 2.

As you walk over to your office, Mary mentions that the IT guy will be coming in later today to fill out some security survey (§ 495.6(d)(15)(i) – Protect Electronic Health Records – Check) and test the export function one more time (§ 495.6(d)(14)(i) – Capability to Exchange Clinical Data – Check) and he is certain that it will work this time. There is a new patient in the freshly cleaned Exam Room 1.

It’s after five o’clock and light snow is falling outside. You saw 20 patients today; some with chronic conditions, some very ill (one had to be admitted) and others with incidental scrapes and viruses, but pretty healthy otherwise. There was nothing unusual about today. On your way home you briefly consider that at this rate you should have plenty of data to report to CMS in 3 months (§ 495.6(d)(10)(i) – Report Quality Measures to CMS – Check) and Mary with the IT guy should figure out the rest when the time comes. That Christmas bonus was well deserved.

This was just one of the 3,653 days until your retirement. The extra three are for leap years.

Congratulations, you are now a Meaningful User of EHR technology.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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Karl Kochendorfer, MDDr. FrankieRichDavid Taobev M.D. Recent comment authors
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Karl Kochendorfer, MD
Guest

Propensity, I just realized that you also posted here about your desire for a search engine feature within an EHR. Please see my comment in the “What’s in an EHR” posting if you want to see a working demo of such a feature: https://thehealthcareblog.com/the_health_care_blog/2010/08/whats-in-an-ehr.html My biggest frustration has always been that we not only need to search for answers about patient-specific questions (“Did this patient ever get the shingles vaccine?”), but we also need to search for clinical questions (“Can and should I give this patient who had shingles ten years ago a vaccine?” AND administrative questions (“Does this patient’s… Read more »

Dr. Frankie
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Dr. Frankie

And now ladies and gentlemen, how about a day in the life of a bunch of frustrated users?
http://hcrenewal.blogspot.com/2010/07/open-question-on-moral-authority-and.html

Nate
Guest
Nate

I have no desire to spread the wealth, I want as much of it right, points down to name, here as I can hold. The only time I want to spread the wealth is when my cup run overith I like a nice spread out spill instead of big puddles

Margalit Gur-Arie
Guest

“Doctors need to stop their whining and open their wallats like the rest of us do. They already live better then 95% of us, I’m getting tired of passing the hat to pay their expenses while they live in bigger houses, drive nicer cars, and have younger wives. ” That is not a very capitalist way of looking at things. Careful Nate, this sounds almost like a desire to “spread the wealth” around…. 🙂 As to paper records, Rich’s story is very typical and there are very few questions in my mind regarding the need for digitizing clinical information. The… Read more »

Nate
Guest
Nate

wonder how much time is spent taking redudenent medical histories? From my personal experience both in regards to medical and non medical digitliastion of data utilization of the data is far less labor entensive. Getting analog data to digital is tough, and the first few weeks of transtion from analog to digital takes som egetting use to but after that there is no question it saves time and is more efficient. I don’t see how using digital data can be more labor intensive then charts that get filed and passed around.

Rich
Guest
Rich

“Yes, but, again, information is not health care. To use all this newly accumulated information in a “meaningful” way will not be like sending out a bank statement; it will require the doc and her staff to use that information in a way that has a positive impact on an individual’s health. And that is very labor-intensive and expensive.” In my experience this week at a leading childrens hospital, my wife and I were queried for relevant medical history information about our child, by various medical professionals in the context of a pre-op meeting – anesthesiologists, nurses, nurse practitioners, doctors.… Read more »

Nate
Guest
Nate

“I don’t know who benefits more.” “Nate, regarding EDI, it is only fair that insurers pay most of the price since they realize most of the efficiencies of electronic claims.” Before you were certain that it benefited insurers and thus they should pay for it, I think you intended and do build upon this to justify insurers, taxpayors, and others getting stuck with the tab for EHRs. While still wrong I can respect and leave it at you don’t know. Maybe you just don’t beleive the math I showed you but it is pretty basic and indisputable. None the less… Read more »

Margalit Gur-Arie
Guest

What does EDI have to do with being liberal, or not?
I have no idea what you are trying to say. Is it that payers are better off on paper? Or are you just saying that providers benefit more than payers from EDI? Does this mean that the Government required EDI to help doctors out?
I don’t know who benefits more. I think both do, or should. If that’s not true, maybe we should ask UHC if they are interested in reverting to paper.

Nate
Guest
Nate

“Nate, when is the last time you actually looked at an 837?” two hours ago, I imported 450 of them today, how about you? Nothing in your latest comment changes the fact that collecting does not impact EDI fees or savings. You have not presented a single credible argument that insurers benefit from EDI more then providers. You made an unsubstantiated claim, got called out on it, and refuse to admit you were wrong. EDI saved doctors paper and postage while insurers had data entry cost off set by EDI fees. You don’t have any argument here, just fix the… Read more »

Margalit Gur-Arie
Guest

Nate, when is the last time you actually looked at an 837? It has dozens of loops and a very complex structure. There are required elements and optional ones. Each element has a predefined format and each payer has its own special rules. Ever so often, billing software will send 837s which are missing required elements, have incorrectly formatted data (e.g. something that should be characters only has numbers in it) and a myriad other things. Clearinghouses stop those 837 and send a message back to the provider that they need to be fixed. Sometimes entire batches fail at the… Read more »

Nate
Guest
Nate

“Providers who outsource billing pay between 5% and 10% of net collections for the service,” Come on Margalit your mixing terms in the same sentenance. Are they billing or collecting? It is much more expensive to collect money then it is to send out a bill. Your 5% or 10% has nothing to do with the cost of billing that is almost all collection. Net collections….hum nothing in their seems to preclude patients, or are you claiming patients are easier to collect from then insurers? Same with billers you should no better then to think paper billing doesn’t require a… Read more »

Margalit Gur-Arie
Guest

Wendell, one obstacle I see is that EHR data is not uniformly structured. There are labs, for example, in codified format and the same labs in scanned documents, of such low quality that not much can be extracted, and some things are in textual format. It also depends in which context a particular term appears.
Not sure of the magnitude of the job here, but it could be an exciting adventure for someone brave enough 🙂

Margalit Gur-Arie
Guest

Yes, a fire or a flood would destroy all paper medical records. I ran into a practice a few years a go that got robbed and they took everything that wasn’t nailed to the walls, including all the charts. I think after Katrina the VA EMR proved its value pretty decisively. However, if you are ever going to help docs make the transition, you must listen and understand their concerns. Many are legitimate. 2K per month for a solo doc is a lot of money. Putting data in the cloud, when you have no idea if you’ll ever get it… Read more »

Margalit Gur-Arie
Guest

Nate, What providers pay for the clearinghouse is only part of the story. They also have to pay for software license, hardware and the biller who now has different work, but it is still payroll and probably higher than an envelope stuffing person. Providers who outsource billing pay between 5% and 10% of net collections for the service, which should give you an idea of how expensive it is to bill insurers. As far as insurers go, clearinghouses do perform a valuable service by rejecting incorrectly formatted claims. I don’t believe insurers have to pay for those. This service should… Read more »

Wendell Murray
Guest

“‘Google’ searching a Chart or an entire rack of Charts is just one of the benefits to come”
All Google’s software does whether on a computer or across the Internet is to create indexes (indices) to data, the exact equivalent is an index to a book.
Lucene is FOSS written originally in Java, then “ported” to other languages, that provides an API for indexing any application and its data. There is certainly similar indexing software provided by Microsoft for its products.
I am still surprised if such search features are not incorporated in all major EMR applications.